Cynde Gamache on Patient ComplianceAn Interview with Cynde Gamache, MA, RN, NE-BC Vice President, Baptist Health Care Chief Nursing Officer, Baptist Hospital, Pensacola, FL

Working in the healthcare industry as a Registered Nurse for more than three decades, Cynde Gamache has a passion for improving care for patients. This personal fervor and commitment revolves around creating conditions by which healthcare organizations can advance in the areas of care quality, safety, and service. Functioning in varying leadership roles for nearly 20 years has provided Gamache with a broad perspective on the operations and challenges currently faced by healthcare systems.



Patients have a tremendous influence on their own health outcomes. Their level of compliance in taking medications, adhering to treatment regimens, and making healthy lifestyle choices can directly influence not only their longevity but their quality of life along the way.

Here are some startling statistics (Assistmed, 2015).
• Approximately 125,000 people with treatable ailments die each year in the U.S. because they do not take their medication properly.
• About 50% of the 2 billion prescriptions filled each year are not taken correctly.
• Up to 21% of patients never fill their original prescriptions.
• 60% of all patients cannot identify their own medications.
• As many as 40% of patients do not adhere to their treatment regimens.
• 23% of nursing home admissions are due to patient noncompliance (380,000 patients).
• 10% of hospital admissions are due to patient noncompliance (3.5 million patients).
• 30-50% of all patients ignore or otherwise compromise instructions concerning their medication.
• 12-20% of patients take other people’s medicines.

Clearly, there is an opportunity to improve patient outcomes by positively influencing patient compliance. Baptist Health Care’s Cynde Gamache is all about improving patient outcomes. In this article, she answers key questions about patient compliance, based on more than 30 years of personal experience as a Registered Nurse, Chief Nursing Officer, and healthcare system executive.

1) How big an issue is patient compliance for most hospitals?
Patient compliance is an important concern for inpatient and outpatient providers across the continuum of care. It is a systemic challenge that impacts patients and their loved ones and has financial repercussions for both patients and providers. Every U.S. health system is aware of the impact of patient compliance on the health of our communities, workforce, families, unnecessary hospitalizations, Emergency Department visits, and further resource utilization. Our challenge is to improve patient compliance through personalized patient care, in order to mitigate these downstream consequences.

2) What are the biggest challenges you face with patient compliance?
As providers we must understand individual patients and what drives them. All too often we may get frustrated with patients we see as “non-compliant.” Look at the person in his or her entirety, taking into account social, environmental, and medication details. We have to understand their perceptions of what is important in order to work with them to increase compliance.

Creating Behavioral Awareness
It is imperative that we ensure patients are aware that compliance is necessary (or that they are not complying with recommended treatment). Patients will not pay attention to compliance with their treatment regime if
they do not understand they suffer from a chronic illness and that there are implications if they are non-compliant. It is quite difficult to modify behaviors that are problematic—especially those influenced by social
settings. Our roles as care providers often involve asking patients to make major lifestyle changes and potentially to give up a behavior seen as enjoyable (e.g., giving up smoking or eating healthy). There is
tension inherent to this purpose that can put our teams in the position of influencing new behaviors that may be viewed as unfavorable by the patient.

Medication Compliance
Compliance with medication is a major issue; challenges may include getting patients to fill their prescriptions, to take their medicines (and as prescribed), and to continue to take medicines after symptoms subside.

3) In which clinical areas is it most difficult to get patients to comply with their treatment regimens?
Compliance is not necessarily tied to demographics, diagnosis, or illness. I have seen challenges across the board. Some areas in which you see them are more common: for example, diet, lifestyle, smoking, diabetes, and obesity. Compliance is also challenging from patient to patient due to lack of health insurance, high deductible consumer plans, and education. Again, it comes back to determining what patients want to accomplish.

4) Are there certain types of patients or certain demographics who are less likely to be compliant with their treatment?
We need to get beyond categories and focus on personalized patient care. Developing trust between patient and the provider is critical. If we can empathize and understand what patients are thinking, they will begin to trust us.
It’s important to see the situation through the patient lens, and inquiry is a critical skill needed by our teams to uncover individual patient needs. How do they perceive us? Do they understand? We must be vigilant to eliminate jargon and not assume or believe a patient should understand. Uncovering the real problem is imperative. For instance, the real problem may not be diabetes management—it could be the patient does not like the shot.

5) What are some of the techniques you have learned or innovated to help increase patient compliance?
We focus in the following areas:
TIME: We need to spend time to understand what patients think. Appreciative inquiry is critical, and we work to explore their values. It is vital to acknowledge if we are not on the same wavelength.
CONTROL: Everyone benefits when we find ways to give patients some form of control. We also need to re-empathize with the loss of autonomy when someone becomes a patient or has to manage a chronic condition. Our goals as providers may be different from the patient. We are most successful when we understand the patient’s paradigm and values.
LISTENING: Acknowledge that patients do know their own bodies. We trust our patients, listen to them, and understand the meaning underneath what is said.
GOALS: Work on small goals that patients can control. Ask them a question—If you could change one small behavior, what would it be? Identify a single step towards the goal and demonstrate success, celebrating it. Be aware that resistance is normal and not just a person being obstinate. What drives that? Is it fear or the social environment with which they work? We cannot take it personally as a provider. We try everything in our power to make them better. We have not failed. We have to allow patients to be responsible for their own progress.
FOLLOW UP: Connect with the patient through discharge call or email. That check-up will further develop the provider-patient relationship and help create accountability, as well as allow them to share a concern that what was prescribed cannot be done.

6) How do patient compliance issues differ in the inpatient vs. outpatient environments?
At Baptist Health Care, our 2020 nursing strategy includes getting nursing caregivers to start dialoguing and opening up lines of communication across our continuum of care. First and foremost, as leaders we need to make communication and information flow more supportively across the care continuum. We also need to make certain we give caregivers in the primary care office, inpatient, and outpatient settings the same, beneficial access to all patient information.

7) What advice/coaching do you give doctors, nurses, and other caregivers to try to improve patient cooperation?
Communication channels are critical. We cannot be too rushed and hurried. As we are talking we need to use open-ended questions and ensure patient understanding. I have not only seen this professionally, but in my own family where there can be a reluctance to ask healthcare professionals important questions and get clarifications. Sometimes patients feel they did not have the time or would be judged as unintelligent. Emphasize that we are there with them and not judging them if initially they do not understand. Use reflective listening. Summarize your understanding and confirm it with the patient. It’s easy for us to say “xyz” and for the patient to say “xyz”—but are they really the same? Have the patient demonstrate his or her understanding. Lastly, motivation to change must come from the patient.

8) Are there any other comments you would like to make?
Look at patients in their total environment—family, culture, etc. These details factor into whether patients can be compliant. If the patient needs to stop smoking and lives with smokers, this only sets up the patient to fail. Get the family to quit. Look deeper into the situation and consider it in the entirety. These environmental factors significantly influence the ability to comply. Find small successes. How have patients approached previous health issues? Are there keys to unlock what was done previously that can be applied to the current situation? Work closely with the individual. Whether we agree or not, the patient has the ability to accept or decline the advice and care we give. Quality may be more important than quantity to understanding the ramifications of every behavior. The BEST way to change behavior and drive compliance is through the use of stories. It helps us to insert ourselves into the situation and understand. Using stories helps us make the connection or connect with another human being about the same challenge—i.e., someone needing to quit smoking can learn about a smoker who has successfully quit.

Printed July 2015 PX Advisor